ENGLEWOOD, Colo. -- A trauma center's upgrade to level 1 by a large hospital here appeared to pay off in saved lives.

Action Points

Explain that the study found significantly reduced mortality rates after a community hospital upgraded its trauma center designation to level 1.

Point out that this was a retrospective analysis of a single institution.

Point out that other factors related to mortality rates, not accounted for in the study, may have changed during the study interval.

ENGLEWOOD, Colo., Jan. 21 -- A trauma center's upgrade to level 1 by a large hospital here appeared to pay off in saved lives.

After new staffing, policies, and protocols, put in place as part of the upgrade, adjusted mortality rates among trauma patients at Swedish Medical Center declined from an average of 3.48% in the five years before the change to 2.50% in the 4.5 years afterward (P=0.001), David Bar-Or, M.D., and colleagues reported in the January issue of Archives of Surgery.

They also found the greatest reductions in mortality were among some of the sickest patients. Those with acute respiratory distress syndrome had adjusted mortality rates of 26.87% before the upgrade, compared with 9.51% afterward (P=0.02).

The findings emerged from data on all 17,413 patients treated in the hospital's trauma center from January 1999 through March 2007. The designation upgrade took effect on January 1, 2003. The hospital is a privately owned facility serving the southern portion of metropolitan Denver.

Patient characteristics and deaths among 9,211 patients treated before the upgrade were compared with those among 7,902 patients afterward. Adjustments included patient age, injury severity score, hypotension on admission, respiration rate, gender, mechanism of injury, and comorbidities.

The upgrade followed the American College of Surgeons' accreditation process. It requires more intensive staffing and implementation of defined procedures and policies for trauma centers designated as level 1.

During the process, Swedish Medical Center established a core group of critical care-certified trauma surgeons, on-site 24 hours per day, who only treated trauma patients. Operating room nurses were also on-site 24 hours per day. Previously, the trauma center was staffed by general surgeons whose caseload included about 15% non-trauma patients and by nurses on call.

The hospital also assembled a medical trauma team to deal with less severely injured patients presenting with comorbidities.

Another staffing change was to have consistent rotation of general surgery and emergency department residents and medical students.

In addition, the upgrade included development of treatment protocols covering seven common trauma conditions, such as acute respiratory distress, chest tube management, and pelvic fracture care. These were more numerous and better defined than pre-existing protocols, the researchers said.

Finally, the hospital instituted regular trauma conferences, basic science and clinical research programs, and a dedicated OR for trauma surgery.

The adjusted odds ratio for death among patients with acute respiratory distress syndrome after the upgrade relative to before was 0.28 (95% CI: 0.10 to 0.83), Dr. Bar-Or and colleagues reported.

Adjusted death rates for patients with other complications, such as sepsis, pneumonia, thromboembolic disorder, or acute respiratory failure, did not change significantly.

In an accompanying commentary, Elliott R. Haut, M.D., of Johns Hopkins, suggested that the improved mortality could have resulted simply from the passage of time and the improvements in overall medical care that go with it. "We should expect lower mortality for patients seen in March 2007 versus January 1998," Dr. Haut wrote.

Dr. Bar-Or responded in an interview that a plot of mortality rates over the study period shows "a very sharp inflection point" coinciding with the upgrade. That suggests the upgrade and the staffing and other changes that went with it were primarily responsible, though "it's not 100% clear," he said.

"You cannot have every hospital become a level 1 center," he said. Nevertheless, the steps taken in the upgrade process could be implemented or adapted by other hospitals not necessarily seeking a level 1 designation, he suggested.

Dr. Haut wrote that it was impossible to know from the Swedish Medical Center report which changes may have contributed most to the improvements.

"The improved survival is likely multifactorial through a combination of mechanisms. Further research could help determine which factor is the 'most' important," he said.

Dr. Haut added, "We may never know, and it may not matter." The important thing, he suggested, is the improved performance shown in the Swedish Medical Center report and elsewhere, indicating that "we as a community of trauma care providers are doing something right."

No external funding for the study was reported. No financial conflicts of interest were reported.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco

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